children

Article
A Complementary Sensory Tool for Children with
Autism Spectrum Disorders
Sabina Barrios-Fernández 1, * , Margarita Gozalo 2 , Beatriz Díaz-González 3 and
Andrés García-Gómez 4
1 Medical-Surgical Therapeutics Department, University of Extremadura, 10003 Cáceres, Spain
2 Psychology and Anthropology Department, University of Extremadura, 10003 Cáceres, Spain;
mgozalo@unex.es
3 Nursing and Occupational Therapy College, University of Extremadura, 10003 Cáceres, Spain;
bdiazgon@alumnos.unex.es
4 Education Sciences Department, University of Extremadura, 10003 Cáceres, Spain; agarcil9@unex.es
* Correspondence: sabinabarrios@unex.es




Received: 30 September 2020; Accepted: 18 November 2020; Published: 20 November 2020


Abstract: Background: Sensory integration (SI) issues are widely described in people with autism
spectrum disorder (ASD), impacting in their daily life and occupations. To improve their quality
of life and occupational performance, we need to improve clinical and educational evaluation and
intervention processes. We aim to develop a tool for measuring SI issues for Spanish children and
adolescents with ASD diagnosis, to be used as a complementary tool to complete the Rivière’s Autism
Spectrum Inventory, a widely used instrument in Spanish speaking places to describe the severity
of ASD symptoms, recently updated with a new sensory scale with three dimensions. Methods:
458 Spanish participants complemented the new questionnaire, initially formed by 73 items with
a 1–5 Likert scale. Results: The instrument finally was composed of 41 items grouped in three
factors: modulation disorders (13 items), discrimination disorders (13 items), and sensory-based
motor disorders (15 items). The goodness-of-fit indices from factor analyses, reliability, and the
analysis of the questionnaire’s classification capability offered good values. Conclusions: The new
questionnaire shows good psychometric properties and seems to be a good complementary tool to
complete new the sensory scale in the Rivière’s Autism Spectrum Inventory.

Keywords: sensory processing; emotional regulation; assessment; autism spectrum disorders

1. Introduction

1.1. Sensory Integration Process

Sensory integration (SI) is “the neurological process that organizes sensations from one’s own
body (internal) and the environment (external) and makes it possible to use the body effectively
within the environment” [1] (p. 11). An adequate organization of sensory information is necessary for
producing adaptive responses in daily life, which includes different end products: motor, cognitive,
behavioral, emotional, or learning outcomes [2]. SI is considered a prerequisite so that more complex
functions, as perceptual-motor and cognitive ones, can be appropriately developed [3].
The SI process runs through a series of stages. Firstly, the sensory organs capture fragments of
sensory information, which can have either an internal or an external origin. Later, that information is
integrated in the central nervous system (CNS) to become a meaningful whole [4]. The SI process takes
place in different brain structures in a coordinated way, classifying, and organizing the sensory flow
through a series of stages. Firstly, in registration, the CNS detects the sensory sensations from our

Children 2020, 7, 244; doi:10.3390/children7110244 www.mdpi.com/journal/children

Children 2020, 7, 244 2 of 14

sensory receptors and we become aware of those sensations [5]. Next, in modulation, the CNS regulates
and processes the sensory stimuli [6]. Then, during discrimination the CNS distinguishes between
different sensory stimuli, perceiving their specific qualities and becoming meaningful [6–8]. Finally,
we elicit a response, intended to adaptive, which can include attention, organization, self-esteem,
self-confidence, movement, reasoning, and learning outcomes [1,7,9]. Within that end products,
and in the group of adaptive motor-based responses, we must refer to praxis. Praxis is the ability to
conceptualize, plan, and execute unusual motor actions. Thus, it allows us to organize and manage a
purposeful interaction with the physical world, thus involving both motor and cognitive skills [8,10].
Although traditionally we have focused in five senses (vision, hearing, smell, taste, and touch),
there are three more sensory systems essential to be successful in daily life: proprioception, vestibular
system, and interoception. Proprioceptive sense reports on sensations from muscles, ligaments,
and joints, providing information about the compression and stretching of muscles and joints.
Proprioception and touch together form the somatosensory pathway, considered essential for praxis
and movement [11,12]. The vestibular system provides information on movement, gravity and balance,
so it is crucial for the building of spatial and temporal relationships [13]. It also provides information
about the speed and the direction of the head movement and our position with relation to gravity [9].
Interoception sense processes sensory stimuli within the body, including body sensations (hunger,
thirst, body temperature, heart, breathing rate, etc.) and emotional states (happiness, sadness, shame,
anger), being intimately related to self-regulation and well-being [14,15].

1.2. Sensory Processing Disorders

When sensations flow in an organized and integrated way, our brain can use those sensations to
form perceptions, behaviors, and learning; when the flow of sensations is disorganized, perception,
behavior, and learning are like a traffic jam at a rush hour [16]. Therefore, when SI is not working
properly, motor, cognitive, emotional, behavioral, and adaptive issues produce a decrease in daily
living functioning and learning [17–20]. This dysfunction can be mild, medium, or severe [21]. Sensory
processing disorder (SPD) is a neurological disorder in which the ability to process and interpret
sensory stimuli results in abnormal responses, causing a decrease in the quality of life and occupational
performance [22,23]. Several models have been developed to understand the SPD [1,6,24], being
Miller’s model one of the most accepted. According to it, SPD can be classified into three categories
with their corresponding subtypes: sensory modulation disorders, sensory discrimination disorders,
and sensory-based motor disorders. Sensory modulation disorders happen when the CNS has problems
in regulating the sensory information (degree, nature, or intensity) resulting in the following subtypes:
sensory over-responsivity (exaggerated response), sensory under-responsivity (lack or insufficient
response), or sensory craving (desperate seeking for sensory information). Sensory discrimination
disorders happen when there is difficulty interpreting the qualities of the sensory stimuli. As a
result, the responses are often slow, and sometimes, wrong. Finally, sensory-based motor disorders
cause difficulty with motor planning and movement, resulting in postural disorder or dyspraxia
subtypes [6,25].

1.3. Autism Spectrum Disorders and SPD Relationships

Taking the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) as
a reference [26], ASD are included in the neurodevelopmental disorders group, and they are defined
by the presence of (a) persistent deficits in social communication and interaction, and (b) restricted,
repetitive patterns of behavior, interests, or activities. Within the (b) criterion and, for the first time
in the DSM, sensory abnormalities were included as “Hyper- or hyporeactivity to sensory input or
unusual interest in sensory aspects of the environment (e.g., apparent indifference to pain/temperature,
adverse response to specific sounds or textures, excessive smelling or touching of objects, visual
fascination with lights or movement)” (p. 50).
Children 2020, 7, 244 3 of 14

With regards to etiology, and although it is widely recognized that genetic and environmental
factors and their interactions contribute to the phenotypes of ASD, the precise causal mechanisms keep
still unclear [27]. On a neuroanatomical basis, it is hypothesized that ASD symptoms should be a
consequence of brain disconnection since hypomyelination of the brain nerves occurs simultaneously
with the main behavioral symptoms [28]. Other studies complement this hypoconnectivity hypothesis
by suggesting that in addition to hypoconnectivity in some regions of the cerebral cortex and at an
interhemispheric level, a compensatory hyperconnectivity between the thalamus and the cerebral
cortex, explaining sensory, and social symptoms [29]. Under this assumption, sensory issues in ASD
have as origin atypical connectivity of neuronal structures. Nevertheless, it seems that topography
of hypoconnectivity in ASD is unique and different from other conditions, such as SPD. In ASD,
areas related to socio-emotional processing are highly affected; whereas, in SPD, there is lower
connectivity in the brain’s perception and integration pathways, which serve as connections for the
auditory, visual, and somatosensory systems involved in SI [30].
SI issues are commonly reported in ASD, compared to their peers [31]. Various studies have tried
to explain the most frequent sensory profiles or those issues that cause the biggest issues in children
with ASD, as well as the proposals of intervention to improve their occupational performance [19,31–37].
With regards to ASD specific sensory profiles, hyporeactivity/under-responsivity is one of the most
consistent issues found [24], although hyperreactivity/over-responsivity and sensory seeking have
been also reported [38]. Several studies have found relationships between the core symptoms of
ASD and sensory impairments, such as repetitive behaviors [34,39], with social communication
and interaction [31,40,41], but also, with movement issues, including coordination, planning,
and timing [42,43], impacting in their daily life [44]. With regards to the interventions, some of
the studies focused on Ayres’s Sensory Integration Therapy [36,45], and others in using specific sensory
techniques and environmental modifications, thus the promotion of ecological approaches to improve
occupational performance [4,37].

1.4. Autism Spectrum Disorders and SPD Assessment

There are different tools to measure SI functioning, including questionnaires, observational
tools, and comprehensive tests administered to the children or adolescents. Some reviews have
been performed to resume information about SI tools, noticing that there are a large number of
proposals [46,47]. Other reviews have checked for the most used SI tools in ASD, providing information
about their characteristics and limitations [48–50]. Some of the most representative instruments are the
Sensory Profile (SP) [51] and its second version (SP2) [52], a group of standardized questionnaires for
assessing sensory processing including the infant, toddler, child, short, and school companion forms,
from birth to 14.11 years. The Sensory Processing Measure (SPM), formed by a set of questionnaires to
assess SI in home and the school, in children between 5–12 years. It also includes self-evaluation forms
to be completed by the children and adolescents. There is a preschool version from 2–5 years [53].
The Sensory Integration and Praxis Test (SIPT) is a comprehensive test formed by 17 subtests to
assess visual, tactile, kinesthetic, and motor tasks in children from 4–8.11 years [16]. There are several
emerging SI assessment tools. The Sensory Processing 3-Dimensions (SP3D) is a tool composed
of a series of task to elicit typical and atypical behavioral responses in children, covering sensory
modulation, discrimination, and sensory-based motor disorders; and by a questionnaire with five
subscales: sensory over-responsiveness, sensory under-responsiveness, sensory craving, postural
disorder, dyspraxia, and sensory discrimination disorder [25,54]. The Evaluation in Ayres Sensory
Integration (EASI) is a comprehensive assessment test for SI which includes measures related to sensory
perception, sensory responsiveness, postural, ocular and bilateral integration, and praxis [24,55].
Tools for ASD assessment, including detection [56,57], diagnosis and measuring changes after
interventions [58,59] are also available. In any case, the assessment of the severity of ASD should be
complete and comprehensive and must include the measure of the SI and its impact in daily life. Within
these tools, the Autism Spectrum Disorders Inventory developed by Rivière [60,61], is a widely used tool
Children 2020, 7, 244 4 of 14

both in 2020,
Children Spain7, and
x FORLatin
PEERAmerica.
REVIEW It examines the severity of ASD by establishing four disease groups: 4 of 14
relationship disorders, communication disorders, anticipation and flexibility, and symbolization,
Rivière’sinAutism
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12 dimensions, all Inventory
of which canwasbe set up from
scored before0 tothe importance
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An advantage
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instrument explains the four levels of affectation in each dimension, it does not define specific behaviors is strongly
recommended.
to observe, so using complementary tools to collect information is strongly recommended.

Figure1.1.Summary
Figure Summaryof ofRivière’s
Rivière’sAutism
AutismSpectrum
SpectrumInventory
Inventory[60,61].
[60,61]. Disease
Disease groups
groups from
fromI–IV
I–IVwith
with
their 12 dimensions correspond to Rivière’s original version. The V scale with the dimensions
their 12 dimensions correspond to Rivière’s original version. The V scale with the dimensions 13–15 13–15
was
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scores are used to describe intermediate stages.
odd scores are used to describe intermediate stages.
1.5. Aim
1.5. Aim
We aim to create a questionnaire to be used as a support for scoring the new sensory scale
in theWe aim to Autism
Rivière’s create a questionnaire to be used
Spectrum Inventory, as a support
a widely for scoring
used tool theASD
to assess newseverity
sensory in
scale in the
Spanish
Rivière’s places.
speaking Autism Spectrum Inventory, a widely used tool to assess ASD severity in Spanish speaking
places.
2. Methods
2. Methods
2.1. Participants
2.1. Participants
The sample was formed by 458 children and adolescents (308 males, 68.7%, and 144 females,
31.3%) The
fromsample
4 to 19was
years (x = 9.6,
formed by dt = 4.42).
458 children and adolescents
Of these, (308 males,with
259 were individuals 68.7%, anddevelopment
typical 144 females,
31.3%) from
(57.2%), 4 to 19 years
145 presented ASD(x clinical
= 9.6, dt diagnosis
= 4.42). Of(32%)
these,and
259 54
were
hadindividuals with typical
other diagnoses development
different than ASD
(57.2%), 145
resulting presented ASD
in intellectual, clinical
sensory, diagnosis
and/or (32%) and 54
motor disabilities had other diagnoses different than ASD
(11.95%).
resulting in intellectual, sensory, and/or motor disabilities (11.95%).
2.2. Procedure
2.2. Procedure
After conducting a literature review, a group of experts in the fields of Occupational Therapy and
Psychology, with clinical
After conducting experience,
a literature created
review, a preliminary
a group version
of experts in theoffields
the tool composed of 73
of Occupational items.
Therapy
Then a pilot studywith
and Psychology, was clinical
carried out with 31 ASD
experience, families
created with diagnosed
a preliminary versionchildren. The
of the tool 50 items with
composed of 73
the best indicators were selected. Participants were recruited using the snowball technique in
items. Then a pilot study was carried out with 31 ASD families with diagnosed children. The 50 items the case
of typical development children, and through different associations, in the case of diagnosed
with the best indicators were selected. Participants were recruited using the snowball technique in children.
The dataof
the case collection was carried children,
typical development out between May anddifferent
and through Augustassociations,
2020. This protocol adheres
in the case to the
of diagnosed
children. The data collection was carried out between May and August 2020. This protocol adheres
to the updates of the Declaration of Helsinki, and the study was approved by the Committee on
Biomedical Ethics of the University of Extremadura (97/2020).
Children 2020, 7, 244 5 of 14

updates of the Declaration of Helsinki, and the study was approved by the Committee on Biomedical
Ethics of the University of Extremadura (97/2020).
Our instrument, the Behavioral Observation on Sensory Stimuli Questionnaire for Parents (BOSS-P)
was administered to the families. They were also asked for socio-demographic data, including age, sex,
clinical diagnosis, intellectual capacity, language level, comorbidities, and the need for aids in their
daily life. Once the questionnaire was administered to the sample, the items were analyzed by the
group of experts, discarding those which did not fit on the theoretical model, being the final version
composed of 41 items (Supplementary Table S1). The BOSS-P was administered together with the
Sensory Profile 2 (SP2) Short Form [63,64] to 31 participants, to obtain validity indicators.

2.3. Instrument
The BOSS-P, a new instrument to better characterize ASD children and adolescents to fulfil the
three new sensory dimensions from Rivière’s Autism Spectrum Inventory based on Miller’s model,
must be completed interviewing with main caregivers, which may answer the 41 items through a
Likert scale with five response options, from 1 to 5 (higher scores mean greater SI dysfunction). It takes
about 25–30 min to complete the interview.

2.4. Statistics
To perform the validation process of the BOSS-P we have carried out: (1) an exploratory factor
analysis (EFA), (2) confirmatory factor analysis (CFA), (3) reliability analysis, (4) the assessment of
concurrent validity through the correlations with the SP2, and (5) provide descriptive statistics from
the typical development and the ASD subsamples.
Because we are handling ordinal variables from a Likert-type scale with five response categories,
the EFA was carried out with the FACTOR software [65–67] using polychoric correlations and robust
methods [68]. Items with factorial weights below 0.30 were excluded. The CFA was carried out with
the IBM SPSS AMOSTM 24 [69] using the Maximum Likelihood estimation procedure, suitable for
Likert-type scales of five response categories. The CFA supports the factorial solution provided by the
EFA and also offers the model of relations between the variables that best fits with the data [70–72].
The evaluation of the model fit was made taking into account the Chi-Square divided by degrees
of freedom (CMIN/DF) and the p of Chi-square following Byrne’s criteria [73]. The statistical p of
Chi-square is dependent on the sample size, so it was convenient to use other goodness-of-fit indicators
choosing the Tucker–Lewis index (TLI), the comparative fit index (CFI) following Hu and Bentler’s
criteria [74], the root-mean-square error of approximation (RMSEA), and the root-mean-square residuals
(RMSR) [75,76].
Ordinal alpha coefficients were calculated [77,78] to assess reliability, considering values >0.70
acceptable and >0.90, excellent [79]. The analysis of the correlations between our tool and the SP2,
the descriptive statistics of the subsamples and the relative operating characteristic (ROC) analysis
were carried out to check the instrument’s ability to classify between the two subsamples, using
the IBM SPSSTM 24 [80] statistical package. Cohen’s d statistic [81] was also calculated to check the
magnitude of the effect size of the differences between the subsamples scores.

3. Results

3.1. Exploratory Factor Analysis

After administering the experimental version of the questionnaire to the sample, a solution of 41
items grouped into three correlated factors was obtained. Bartlett’s (5025.4; df = 820; p = 0.000) and
Kaiser–Meyer–Olkin test (0.912) statistics showed a very good sample suitability [82]. In Table 1, can be
found both the rotated factorial matrix and factorial weights of each item. The three factors obtained
represent (F1) modulation disorders with 13 items, (F2) discrimination disorders with 13 items, and (F3)
sensory-based motor disorders with 15 items.
Children 2020, 7, 244 6 of 14

Table 1. Rotated factorial matrix and factorial weights of each item.

Items F1 F2 F3
1. Shows disproportionate reactions if touched. 0.491
2. Shows panic reactions to loud noises. 0.624
3. Shows rejection of water when showering or washing. 0.340
4. He is bothered by noisy and crowded places. 0.829
5. When something goes wrong, it takes a long time to calm down. 0.566
6. Shows discomfort with activities that involve spinning. 0.507
7. Cannot concentrate or perform tasks when background noise. 0.627
8. He gets agitated in the presence of very powerful light sources. 0.760
9. Frequently touches or puts body parts or objects in his mouth. 0.394
10. He is bothered with strong smells. 0.702
11. Some clothes bother him; he feels itchy about some fabrics. 0.730
12. He dislikes personal hygiene or grooming activities. 0.452
13. Quick movements are unpleasant for him. 0.643
14. Attends to his name or when he is called. 0.492
15. Communicates feelings aimed at satisfying basic needs. 0.620
16. Realizes when he is tired or exhausted. 0.639
17. Shows comfort when hugged by parents or close relatives. 0.837
18. Shows satisfaction when basic needs are met 0.959
19. When he is disconsolate, he gets calmed by his parents. 0.720
20. Expresses enjoyment or feels comfortable in certain situations. 0.897
21. Can perceive danger in situations that could harm. 0.475
22. Can identify basic emotions in himself and others. 0.442
23. Can orientate himself in the environment. 0.418
24. Notices that his heart is racing when he is tired or excited. 0.522
25. Recognizes the elements that make him nervous. 0.578
26. Has difficulty in recognizing people’s faces. 0.374
27. Has difficulty identifying parts of his own body. 0.655
28. Presents inability to reproduce speech movements. 0.737
29. Can ride a bicycle, rollerblades or a skateboard. 0.623
30. Can perform simple motor imitations. 0.724
31. Can fasten buttons or make loops to get dressed. 0.927
32. Can stack small blocks or string beads on a string. 0.569
33. Can use cutlery with both hands. 0.634
34. Can make copies from simple drawings. 0.930
35. Shows clumsiness in typing or using the computer keyboard. 0.814
36. Shows insecurity going downstairs/hills, holds on to railings. 0.485
37. Can adjust his strength when grasping objects. 0.452
38. Can cut with scissors properly for his age. 0.929
39. Can draw or colour within the proposed margins. 0.924
40. Can follow motor imitations containing multiple steps. 0.892
41. Can complete drawings with one half of it missing. 0.930
(F1) Modulation disorders; (F2) discrimination disorders; and (F3) sensory-based motor disorders. Items translated
for readability; no cross-cultural adaptation performed.

With regards to the correlation between factors, moderate relationships were found between
F1–F2 (0.38); F1–F3 (0.61), and F2–F3 (0.53) [81], which was to be expected since they are different
stages within the same neurobiological process.

3.2. Confirmatory Factor Analysis

The CFA confirms the exploratory factorial solution revealing three latent variables which group
the 41 observable variables (items). Figure 2 shows the graphical representation of the analyzed
model, being (F1) modulation disorders, (F2) discrimination disorders, and (F3) sensory-based motor
disorders. The factorial weights of every item and the covariation relations between the latent variables
are shown.
 3.2. Confirmatory Factor Analysis
The CFA confirms the exploratory factorial solution revealing three latent variables which group
the 41 observable variables (items). Figure 2 shows the graphical representation of the analyzed
model, being (F1) modulation disorders, (F2) discrimination disorders, and (F3) sensory-based motor
disorders.
Children The factorial weights of every item and the covariation relations between the latent
2020, 7, 244 7 of 14
variables are shown.

Figure
Figure 2. The
2. The Behavioral
Behavioral Observation
Observation on Sensory
on Sensory Stimuli
Stimuli Questionnaire
Questionnaire for Parents’
for Parents’ (BOSS-P)
(BOSS-P) graphical
graphical representation
representation after confirmatory
after confirmatory factor
factor analysis analysis (CFA).
(CFA).

In In Table
Table 2, 2,
areare representedthe
represented thegoodness-of-fit
goodness-of-fitindices
indices from
from the
the CFA,
CFA, showing
showinggood
goodvalues.
values.

Table
Table 2. 2.BOSS-P
BOSS-Pgoodness-of-fit
goodness-of-fitindices
indices from
from the
the confirmatory
confirmatoryfactor
factoranalysis
analysis(CFA).
(CFA).
Indices Cut-Off Value
Indices Cut-Off Value
CMIN/DF <2 1.995
p (χ2) CMIN/DF
>0.05<2 1.995
0.000
p (χ2 ) >0.05 0.000
TLI >0.90 0.912
TLI >0.90 0.912
CFI CFI >0.90
>0.90 0.925 0.925
RMSEA RMSEA <0.06 <0.06 0.047 (0.043–0.051)
0.047 (0.043–0.051)
RMSR RMSR <0.08 <0.08 0.071 0.071
p (χp2 ):
(χchi-squared
2): chi-squared probability; CFI: comparative fit index; NNFI: non-normed fit index, RMSEA: root
probability; CFI: comparative fit index; NNFI: non-normed fit index, RMSEA: root mean square
error
meanof approximation; RMSR:
square error of root mean square
approximation; RMSR:ofrootresiduals.
mean square of residuals.

3.3. Reliability
To analyze the concurrent validity, we compared the BOSS-P with the SP2, a tool for SI assessment
validated for Spanish children and adolescents. Both questionnaires were administered to 31
participants with ASD to study their correlations. As shown in Table 3, the modulation disorders
factor (F1) from the BOSS-P was the only with significant and moderate correlations with the factors
analyzed in the SP2.
 Children 2020, 7, 244 8 of 14

Table 3. Correlation matrix between the Behavioral Observation on Sensory Stimuli Questionnaire for
Parents (BOSS-P) and the Short Sensory Profile 2 (SP2).

BOSS-P SP2
F1 F2 F3 Total Sensory Behavioral Total
F1 1
F2 −0.076 1
F3 −0.134 0.297 1
Total 0.438 * 0.636 ** 0.701 ** 1
Sensory 0.448 * 0.084 0.027 0.309 1
Behaviour 0.600 ** 0.034 0.147 0.446 * 0.613 ** 1
total 0.590 ** 0.063 0.103 0.426 * 0.879 ** 0.915 ** 1
*. Correlation is significant at the 0.05 level (2-tailed). **. Correlation is significant at the 0.01 level (2-tailed)
F1 = Modulation Disorders factor; F2 = Discrimination Disorders factor; F3 = Sensory-Based Motor Disorders factor;
Sensory = Sensory Processing; Behavioral = Behavioral Responses associated with Sensory Processing.

3.4. Questionnaire’s Capability to Classify between ASD and Typical Development

Descriptive statistics of participants with ASD (n = 145) and with typical development (n = 259)
subsamples are shown in Table 4. It can be checked that both, mean and standard deviation of every
subsample offer different scores.

Table 4. Descriptive statistics of ASD and typical development samples.

Autism Spectrum Disorder Typical Development

F1 F2 F3 Total F1 F2 F3 Total
x 33.8 31.9 40.3 106 24.8 20.5 23.1 68.4
SD 8.9 8.0 11.9 19 7.7 5.5 7.8 16.0
x: mean; SD: standard deviation.

In Figure 3, graphical representation and statistics from ROC curves are provided. The area under
the curve (AUC) shows differences with large effect magnitudes between the three factors, being the
BOSS-P
Children total
2020, 7, xscore the most
FOR PEER capable dimension to establish a correct classification of subjects according
REVIEW 9 of 14
to their reference group.

(a) (b)
Figure
Figure3.3.Graphical
Graphicalrepresentation
representation(a)(a)and
andstatistics
statistics(b)
(b)from
fromthe
thereceiver
receiveroperating
operatingcharacteristic
characteristic
(ROC)
(ROC)curves.
curves.

Table 5. Combination of the level of affectation in the Rivière’s Inventory and the Behavioral
Observation on Sensory Stimuli Questionnaire for Parents’ (BOSS-P) interquartile scores.

BOSS-P
F1 F2 F3
Children 2020, 7, 244 9 of 14

Considering the Rivière’s Autism Spectrum Inventory scoring system, an approximation to the
level of SI severity using the level of affectation in the Rivière’s inventory and the BOSS-P interquartile
scores was obtained in the ASD sample (see Table 5).

Table 5. Combination of the level of affectation in the Rivière’s Inventory and the Behavioral Observation
on Sensory Stimuli Questionnaire for Parents’ (BOSS-P) interquartile scores.

BOSS-P
F1 F2 F3
1 (8 points) >40 >36 >50
2 (6 points) 34–40 30–36 40–50
Rivière’s inventory levels of severity
3 (4 points) 27–34 27–30 31.5–40
4 (2 points) <27 <27 <31.5
F1 = modulation disorders factor; F2 = discrimination disorders factor; F3 = sensory-based motor disorders factor.

4. Discussion

4.1. About the BOSS-P Questionnaire

We aimed to create a questionnaire to support the new SI scale [62] added to the Rivière’s Autism
Spectrum Inventory [60,61]. The Rivière’s Inventory is a widely used instrument in Spain and Latin
America, which allows us to establish the level of the ASD severity, in line with the levels proposed in
the DSM-5 [26]. The Rivière’s Inventory is useful both during the diagnosis and intervention processes.
The BOSS-P is a screening instrument, administered through an interview with parents or carers,
which is not intended to replace other comprehensive assessments, existing or emerging, with good
psychometric properties on SI. However, our instrument has several advantages: (1) it is a quick test
which is administered in 25–30 min; (2) that does not require specific training; (3) is open access; (4) is a
complete tool, as it assesses items within the three areas described by Miller [6]: sensory modulation,
sensory discrimination, and sensory-based motor disorders; (5) with good psychometric properties in
terms of validity, reliability, and discrimination capacity; (6) created in Spain and therefore, adapted to
the cultural characteristics of this country; (7) which fills a gap in terms of SI tools in Spanish-speaking
population; and (8) which complements a psychological test widely used in the Spanish-speaking
world, the Rivière’s Inventory for people with ASD.
We have also provided an attempt to the combined use of the BOSS-P and the Rivière’s Inventory,
by linking the Rivière’s level of severity and the BOSS-P quartile scores. Our instrument showed good
psychometric values, offering a factorial structure formed by the three groups proposed by Miller [6].
These data are interesting because let us verify that Miller’s model is consistent in different cultures
and because. The BOSS-P’s ability to classify between participants with ASD and typical development
children seems adequate (AUC = 0.938), corresponding to a large effect size between the scores of both
subsamples (d = 2.176) [83].

4.2. The BOSS-P and Other Instruments

Some reviews have found that psychometric properties of some of the SI tools are from poor to
moderate, so the professionals must use the obtained data with caution [48,50], selecting appropriate
SI assessments depending on the detected SI needs [47]. However, as aforementioned, there are
few available instruments for Spanish children and adolescents. According to our best knowledge,
neither the SIPT—considered as a Gold Standard for SI assessment [84]—nor the SPM are available for
Spanish population, while the SP3D and the EASI are not yet published, being the SP2 the only tool of
choice in Spain. The SP2 Spanish version covers a little shorter age range than the original, from 3 to
14.11 years. The BOSS-P covers from 4 to 19 years, a wider range including the full adolescent stage.
The correlations between the BOSS-P and the SP2 only find relationships in modulation disorders,
Children 2020, 7, 244 10 of 14

which could lead us to consider the necessity of using different tools to obtain information about SI if
using the SP2.
Concerning its psychometric properties, the BOSS-P items present excellent internal consistency
(alpha > 0.87), similar or superior other questionnaires used in the international context [46]. The ability
of the questionnaire to discriminate between sub-samples offers a large effect size (d = 2.176), which is
slightly higher than the size effect of the difference reported in other instruments [85].

4.3. Limitations and Future Lines

This research has some limitations. The information was completed through parents, and although
instruments completed by families are considered to be valid [86], we must be careful because some
parents should overestimate or underestimate the development of their children [87]. The sample was
one of convenience. Another limitation was that we could not perform a test–retest. As future lines,
we will try to improve the psychometric properties of the questionnaire, as well as to perform studies
for its use in other Spanish-speaking countries different than Spain.

5. Conclusions
The preliminary study of the psychometric properties of Behavioral Observation on Sensory
Stimuli Questionnaire for Parents (BOSS-P) shows good values for its use in Spanish children and
adolescents diagnosed with ASD between 4 and 19 years. This tool was designed to help clinicians
and educational professionals to establish the level of severity in children and adolescents with ASD
diagnosis through the new SI scale in the Rivière’s Autism Spectrum Inventory.

Supplementary Materials: The following are available online at http://www.mdpi.com/2227-9067/7/11/244/s1,

Table S1: Behavioral Observation on Sensory Stimuli Questionnaire for Parents (BOSS-P) Versión original española:
Cuestionario de Observación de la Conducta ante Estímulos Sensoriales para Padres de niños/as y adolescentes
con Autismo/TEA (OCS-P).
Author Contributions: Conceptualization, S.B.-F., M.G., and B.D.-G.; Methodology, A.G.-G.; Software, A.G.-G.;
Formal analysis, A.G.-G.; Writing—original draft preparation, S.B.-F., M.G.; Writing—review and editing, S.B.-F.
and M.G.; Supervision, A.G.-G. All authors have read and agreed to the published version of the manuscript.
Funding: This research received no external funding.
Acknowledgments: We want to thank all the participants who kindly dedicated their time to help us in
this research.
Conflicts of Interest: The authors declare no conflict of interest.

References
1. Ayres, A.J. Sensory Integration and Learning Disorders; Western Psychological Services: Los Angeles, CA, USA,
1972; ISBN 978-0-87424-303-1.
2. Humphries, T.; Wright, M.; McDougall, B.; Vertes, J. The Efficacy of Sensory Integration Therapy for Children
with Learning Disability. Phys. Occup. Ther. Pediatr. 1990, 10, 1–17. [CrossRef]
3. Williams, M.S.; Shellenberger, S. The Alert Program for Self-Regulation; TherapyWorks Inc.: Albuquerque, NM,
USA, 1995; ISBN 978-0-9643041-1-6.
4. Dunn, W. Supporting Children to Participate Successfully in Everyday Life by Using Sensory Processing
Knowledge. Infants Young Child. 2007, 20, 84–101. [CrossRef]
5. Kilroy, E.; Aziz-Zadeh, L.; Cermak, S.A. Ayres Theories of Autism and Sensory Integration Revisited:
What Contemporary Neuroscience Has to Say. Brain Sci. 2019, 9, 68. [CrossRef]
6. Miller, L.J.; Anzalone, M.E.; Lane, S.J.; Cermak, S.A.; Osten, E.T. Concept Evolution in Sensory Integration:
A Proposed Nosology for Diagnosis. Am. J. Occup. Ther. 2007, 61, 135–140. [CrossRef]
7. Sher, B. Everyday Games for Sensory Processing Disorder: 100 Playful Activities to Empower Children with Sensory
Differences; Althea Press: Berkeley, CA, USA, 2016; ISBN 978-1-62315-700-5.
8. Lane, S.J.; Bundy, A.C. Kids Can Be Kids: A Childhood Occupations Approach; Lane, S., Bundy, A.C., Eds.;
F.A. Davis Co.: Philadelphia, PA, USA, 2012; ISBN 978-0-8036-1228-0.
Children 2020, 7, 244 11 of 14

9. Lane, S.J.; Mailloux, Z.; Schoen, S.; Bundy, A.; May-Benson, T.A.; Parham, L.D.; Roley, S.S.; Schaaf, R.C.
Neural Foundations of Ayres Sensory Integration® . Brain Sci. 2019, 9, 153. [CrossRef]
10. Cermak, S.A. Reflections on 25 Years of Dyspraxia Research. In Ayres Dyspraxia Monograph; Pediatric Therapy
Network: Torrance, CA, USA, 2011.
11. Ackerley, R.; Kavounoudias, A. The role of tactile afference in shaping motor behaviour and implications for
prosthetic innovation. Neuropsychologia 2015, 79, 192–205. [CrossRef]
12. Beaudry Bellefeuille, I.; Sánchez Padrón, O. Tengo Duendes en Las Piernas; Nobel: Oviedo, Spain, 2011;
ISBN 978-84-8459-654-7.
13. Pfeiffer, C.; Serino, A.; Blanke, O. The vestibular system: A spatial reference for bodily self-consciousness.
Front. Integr. Neurosci. 2014, 8, 31. [CrossRef]
14. Mahler, K.J.; Craig, A.D. Interoception: The Eighth Sensory System: Practical Solutions for Improving
Self-Regulation, Self-Awareness and Social Understanding of Individuals with Autism Spectrum and Related
Disorders; AAPC Publishing: Shawnee Mission, KS, USA, 2016; ISBN 978-1-942197-14-0.
15. Farb, N.A.S.; Daubenmier, J.; Price, C.J.; Gard, T.; E Kerr, C.; Dunn, B.D.; Klein, A.C.; Paulus, M.P.;
Mehling, W.E. Interoception, contemplative practice, and health. Front. Psychol. 2015, 6, 763. [CrossRef]
16. Ayres, A.J. Sensory Integration and Praxis Tests; Western Psychological Services: Los Angeles, CA, USA, 1989.
17. Gourley, L.; Wind, C.; Henninger, E.M.; Chinitz, S. Sensory Processing Difficulties, Behavioral Problems,
and Parental Stress in a Clinical Population of Young Children. J. Child Fam. Stud. 2013, 22, 912–921.
[CrossRef]
18. Miller, L.J.; Nielsen, D.M.; Schoen, S.; Brett-Green, B.A. Perspectives on sensory processing disorder: A call
for translational research. Front. Integr. Neurosci. 2009, 3, 3. [CrossRef]
19. Galiana-Simal, A.; Vela-Romero, M.; Romero-Vela, V.M.; Oliver-Tercero, N.; García-Olmo, V.;
Benito-Castellanos, P.J.; Muñoz-Martinez, V.; Beato-Fernandez, L. Sensory processing disorder: Key points of
a frequent alteration in neurodevelopmental disorders. Cogent Med. 2020, 7. [CrossRef]
20. Butera, C.; Ring, P.; Sideris, J.; Jayashankar, A.; Kilroy, E.; Harrison, L.; Cermak, S.; Aziz-Zadeh, L. Impact
of Sensory Processing on School Performance Outcomes in High Functioning Individuals with Autism
Spectrum Disorder. Mind Brain Educ. 2020, 14, 243–254. [CrossRef]
21. Baranek, G.T.; David, F.J.; Poe, M.D.; Stone, W.L.; Watson, L.R. Sensory Experiences Questionnaire:
Discriminating sensory features in young children with autism, developmental delays, and typical
development. J. Child Psychol. Psychiatry 2006, 47, 591–601. [CrossRef] [PubMed]
22. Dunn, W. The Sensations of Everyday Life: Empirical, Theoretical, and Pragmatic Considerations. Am. J.
Occup. Ther. 2001, 55, 608–620. [CrossRef] [PubMed]
23. Ismael, N.; Lawson, L.M.; Hartwell, J. Relationship Between Sensory Processing and Participation in Daily
Occupations for Children with Autism Spectrum Disorder: A Systematic Review of Studies That Used
Dunn’s Sensory Processing Framework. Am. J. Occup. Ther. 2018, 72. [CrossRef]
24. Schaaf, R.C.; Mailloux, Z. Clinician’s Guide for Implementing Ayres Sensory Integration: Promoting Participation
for Children with Autism; AOTA Press: Bethesda, MD, USA, 2015; ISBN 978-1-56900-365-7.
25. Mulligan, S.; A Schoen, S.; Miller, L.J.; Valdez, A.; Magalhaes, D. The Sensory Processing 3-Dimensions Scale:
Initial Studies of Reliability and Item Analyses. Open J. Occup. Ther. 2019, 7, 4. [CrossRef]
26. APA. Diagnostic and Statistical Manual of Mental Disorders, 5th ed.; American Psychiatric Association:
Washington, DC, USA, 2013; p. 5.
27. Bölte, S.; Girdler, S.; Marschik, P.B. The contribution of environmental exposure to the etiology of autism
spectrum disorder. Cell. Mol. Life Sci. 2019, 76, 1275–1297. [CrossRef]
28. Steinman, G.; Mankuta, D. Molecular biology of autism’s etiology—An alternative mechanism.
Med. Hypotheses 2019, 130, 109–272. [CrossRef]
29. Linke, A.C.; Keehn, R.J.J.; Pueschel, E.B.; Fishman, I.; Müller, R.-A. Children with ASD show links between
aberrant sound processing, social symptoms, and atypical auditory interhemispheric and thalamocortical
functional connectivity. Dev. Cogn. Neurosci. 2018, 29, 117–126. [CrossRef]
30. Chang, Y.-S.; Owen, J.P.; Desai, S.S.; Hill, S.S.; Arnett, A.B.; Harris, J.; Marco, E.J.; Mukherjee, P. Autism
and Sensory Processing Disorders: Shared White Matter Disruption in Sensory Pathways but Divergent
Connectivity in Social-Emotional Pathways. PLoS ONE 2014, 9, e103038. [CrossRef]
31. Schaaf, R.C.; Lane, A.E. Toward a Best-Practice Protocol for Assessment of Sensory Features in ASD. J. Autism
Dev. Disord. 2015, 45, 1380–1395. [CrossRef] [PubMed]
Children 2020, 7, 244 12 of 14

32. Posar, A.; Visconti, P. Sensory abnormalities in children with autism spectrum disorder. J. Pediatr. 2018, 94,
342–350. [CrossRef]
33. Marco, E.J.; Hinkley, L.B.N.; Hill, S.S.; Nagarajan, S.S. Sensory Processing in Autism: A Review of
Neurophysiologic Findings. Pediatr. Res. 2011, 69, 48R–54R. [CrossRef] [PubMed]
34. Suarez, M.A. Sensory Processing in Children with Autism Spectrum Disorders and Impact on Functioning.
Pediatr. Clin. North Am. 2012, 59, 203–214. [CrossRef] [PubMed]
35. Glod, M.; Riby, D.M.; Rodgers, J. Sensory processing profiles and autistic symptoms as predictive factors in
autism spectrum disorder and Williams syndrome. J. Intellect. Disabil. Res. 2020, 64, 657–665. [CrossRef]
[PubMed]
36. Schoen, S.; Lane, S.J.; Mailloux, Z.; May-Benson, T.; Parham, L.D.; Roley, S.S.; Schaaf, R.C. A systematic review
of ayres sensory integration intervention for children with autism. Autism Res. 2019, 12, 6–19. [CrossRef]
[PubMed]
37. Bodison, S.C.; Parham, L.D. Specific Sensory Techniques and Sensory Environmental Modifications for
Children and Youth with Sensory Integration Difficulties: A Systematic Review. Am. J. Occup. Ther. 2017, 72,
72011–90040. [CrossRef]
38. Ben-Sasson, A.; Hen, L.; Fluss, R.; Cermak, S.A.; Engel-Yeger, B.; Gal, E. A Meta-Analysis of Sensory
Modulation Symptoms in Individuals with Autism Spectrum Disorders. J. Autism Dev. Disord. 2009, 39,
1–11. [CrossRef]
39. Di Renzo, M.; Di Castelbianco, F.B.; Vanadia, E.; Petrillo, M.; Racinaro, L.; Rea, M. Sensory Processing and
Repetitive Behaviors in Clinical Assessment of Preschool Children with Autism Spectrum Disorder. J. Child
Adolesc. Behav. 2017, 5, 5. [CrossRef]
40. Dakopolos, A.J.; Jahromi, L.B. Differences in sensory responses among children with autism spectrum
disorder and typical development: Links to joint attention and social competence. Infant Child Dev. 2018, 28,
e2117. [CrossRef]
41. Thye, M.D.; Bednarz, H.M.; Herringshaw, A.J.; Sartin, E.B.; Kana, R.K. The impact of atypical sensory
processing on social impairments in autism spectrum disorder. Dev. Cogn. Neurosci. 2018, 29, 151–167.
[CrossRef] [PubMed]
42. Miller, M.; Chukoskie, L.; Zinni, M.; Townsend, J.; Trauner, D. Dyspraxia, motor function and visual–motor
integration in autism. Behav. Brain Res. 2014, 269, 95–102. [CrossRef] [PubMed]
43. Kaur, M.; Srinivasan, S.M.; Bhat, A.N. Comparing motor performance, praxis, coordination, and interpersonal
synchrony between children with and without Autism Spectrum Disorder (ASD). Res. Dev. Disabil. 2018, 72,
79–95. [CrossRef] [PubMed]
44. Günal, A.; Bumin, G.; Huri, M. The Effects of Motor and Cognitive Impairments on Daily Living Activities
and Quality of Life in Children with Autism. J. Occup. Ther. Sch. Early Interv. 2019, 12, 444–454. [CrossRef]
45. Wong, C.; Odom, S.L.; Hume, K.A.; Cox, A.W.; Fettig, A.; Kucharczyk, S.; Brock, M.E.; Plavnick, J.B.;
Fleury, V.P.; Schultz, T.R. Evidence-Based Practices for Children, Youth, and Young Adults with Autism
Spectrum Disorder: A Comprehensive Review. J. Autism Dev. Disord. 2015, 45, 1951–1966. [CrossRef]
46. Jorquera-Cabrera, S.; Romero-Ayuso, D.; Rodriguez-Gil, G.; Triviño-Juárez, J.-M. Assessment of Sensory
Processing Characteristics in Children between 3 and 11 Years Old: A Systematic Review. Front. Pediatr.
2017, 5, 57. [CrossRef]
47. Eeles, A.L.; Spittle, A.J.; Anderson, P.J.; Brown, N.; Lee, K.J.; Boyd, R.; Doyle, L.W. Assessments of sensory
processing in infants: A systematic review. Dev. Med. Child Neurol. 2012, 55, 314–326. [CrossRef]
48. Burns, C.O.; Dixon, D.R.; Novack, M.; Granpeesheh, D. A Systematic Review of Assessments for Sensory
Processing Abnormalities in Autism Spectrum Disorder. Rev. J. Autism Dev. Disord. 2017, 4, 209–224.
[CrossRef]
49. Dubois, D.; Lymer, E.; Gibson, B.E.; Desarkar, P.; Nalder, E.J. Assessing Sensory Processing Dysfunction
in Adults and Adolescents with Autism Spectrum Disorder: A Scoping Review. Brain Sci. 2017, 7, 108.
[CrossRef]
50. Yeung, L.H.J.; Thomacos, N. Assessments of sensory processing in infants and children with autism spectrum
disorder between 0–12 years old: A scoping review. Res. Autism Spectr. Disord. 2020, 72, 101517. [CrossRef]
51. Dunn, W. Sensory Profile User’s Manual; Pearson Psychcop: San Antonio, TX, USA, 1999.
52. Dunn, W. Sensory Profile 2 Manual; Pearson Psychcop: San Antonio, TX, USA, 2014.
Children 2020, 7, 244 13 of 14

53. Parham, L.D.; Ecker, C.; Miller Kuhaneck, H.; Henry, D.A.; Glennon, T.J. Sensory Processing Measure (SPM):
Manual; Western Psychological Services: Los Angeles, CA, USA, 2007.
54. Mulligan, S.; Schoen, S.; Miller, L. Scientific Research Panel 304C Reliability and Item Analyses of the Sensory
Processing 3-Dimensions Scale. Am. J. Occup. Ther. 2018, 72, 7211500055. [CrossRef]
55. Mailloux, Z.; Parham, L.D.; Roley, S.S.; Ruzzano, L.; Schaaf, R.C. Introduction to the Evaluation in Ayres
Sensory Integration® (EASI). Am. J. Occup. Ther. 2017, 72, 72011–95030. [CrossRef]
56. Petrocchi, S.; Levante, A.; Lecciso, F. Systematic Review of Level 1 and Level 2 Screening Tools for Autism
Spectrum Disorders in Toddlers. Brain Sci. 2020, 10, 180. [CrossRef]
57. Towle, P.O.; Patrick, P.A. Autism Spectrum Disorder Screening Instruments for Very Young Children:
A Systematic Review. Autism Res. Treat. 2016, 2016, 1–29. [CrossRef]
58. Payakachat, N.; Tilford, J.M.; Kovacs, E.; Kuhlthau, K. Autism spectrum disorders: A review of measures
for clinical, health services and cost–effectiveness applications. Expert Rev. Pharm. Outcomes Res. 2012, 12,
485–503. [CrossRef]
59. Randall, M.; Egberts, K.J.; Samtani, A.; Scholten, R.J.; Hooft, L.; Livingstone, N.; Sterling-Levis, K.;
Woolfenden, S.; Williams, K. Diagnostic tests for autism spectrum disorder (ASD) in preschool children.
Cochrane Database Syst. Rev. 2018, 7, CD009044. [CrossRef]
60. Rivière, Á. Tratamiento y Definición del Espectro Autista. In Tratamiento del Autismo. Nuevas Perspectivas;
Instituto de Migraciones y Servicios Sociales: Madrid, Spain, 1998; ISBN 84-88986-70-X.
61. Rivière, A. IDEA: Inventario de Espectro Autista; Fundec: Buenos Aires, Argentina, 2002.
62. García-Gómez, A. A proposal of three additional dimensions to the Rivière’s Autism Spectrum Inventory.
Psicol. Educ. in press. [CrossRef]
63. Williams, Z.J.; Failla, M.D.; Gotham, K.O.; Woynaroski, T.G.; Cascio, C. Psychometric Evaluation of the
Short Sensory Profile in Youth with Autism Spectrum Disorder. J. Autism Dev. Disord. 2018, 48, 4231–4249.
[CrossRef]
64. Dunn, W. Perfil Sensorial 2 Breve; Adaptación Española; Pearson Psychcop: Madrid, Spain, 2016;
ISBN 978-84-9035-547-3.
65. Ferrando, P.J.; Lorenzo-Seva, U. Program FACTOR at 10: Origins, development and future directions.
Psicothema 2017, 29, 236–240.
66. Lorenzo-Seva, U.; Ferrando, P.J. Factor: A computer program to fit the exploratory factor analysis model.
Behav. Res. Methods 2006, 38, 88–91. [CrossRef]
67. Manual of the Program. Available online: http://psico.fcep.urv.es/utilitats/factor/documentation/Manual-of-
the-Factor-Program-v92.pdf (accessed on 20 August 2020).
68. Timmerman, M.E.; Lorenzo-Seva, U. Dimensionality assessment of ordered polytomous items with parallel
analysis. Psychol. Methods 2011, 16, 209–220. [CrossRef] [PubMed]
69. Arbuckle, J. Amos 24.0 User’s Guide; IBM SPSS: Chicago, IL, USA, 2015.
70. Flora, D.B.; LaBrish, C.; Chalmers, R.P. Old and New Ideas for Data Screening and Assumption Testing for
Exploratory and Confirmatory Factor Analysis. Front. Psychol. 2012, 3, 3. [CrossRef]
71. Lloret-Segura, S.; Ferreres-Traver, A.; Hernández-Baeza, A.; Tomás-Marco, I. Exploratory Item Factor Analysis:
A practical guide revised and updated. An. Psicol. 2014, 30, 1151–1169. [CrossRef]
72. Ferrando, P.J.; Anguiano-Carrasco, C. Factor analysis as a research technique in psychology. Pap. Psicólogo
2010, 31, 18–33.
73. Byrne, B.M. A Primer of LISREL. In Texto original: Basic Applications and Programming for Confirmatory Factor
Analytic Models; Springer: New York, NY, USA, 1989; ISBN 978-1-4613-8887-6.
74. Hu, L.-T.; Bentler, P.M. Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria
versus new alternatives. Struct. Equ. Model. Multidiscip. J. 1999, 6, 1–55.
75. Hair, J.F. Multivariate Data Analysis: A Global Perspective; Pearson Education: London, UK, 2010;
ISBN 978-0-13-515309-3.
76. Browne, M.W.; Cudeck, R. Alternative Ways of Assessing Model Fit. Sociol. Methods Res. 1992, 21, 230–258.
[CrossRef]
77. Gadermann, A.M.; Guhn, M.; Zumbo, B.D. Ordinal Alpha. Encycl. Qual. Life Well Being Res. 2014, 4513–4515.
[CrossRef]
78. Oliden, P.E.; Zumbo, B.D. Reliability coefficients for ordinal response scales. Psicothema 2008, 20, 896–901.
Children 2020, 7, 244 14 of 14

79. Pallant, J. SPSS Survival Manual: A Step by Step Guide to Data Analysis Using IBM SPSS, 5th ed.; McGraw Hill:
Berkshire, UK, 2013; ISBN 978-0-335-26258-8.
80. IBM Corp IBM SPSS Statistics for Windows, Version 24.0. Available online: https://he02.tci-thaijo.org/index.
php/ramajournal/statistical_software_references_format (accessed on 22 August 2020).
81. Cohen, J. Statistical Power Analysis for the Behavioral Sciences. Lawrence Earlbaum Associates Hillsdale,
NJ, USA. Available online: http://www.utstat.toronto.edu/~{}brunner/oldclass/378f16/readings/CohenPower.pdf
(accessed on 15 October 2020).
82. Jöreskog, K.G.; Sörbom, D. LISREL 8: Structural Equation Modeling with the SIMPLIS Command Language;
Scientific Software International: Lincolnwood, IL, USA, 1993; ISBN 978-0-89498-033-6.
83. Salgado, J.F. Transforming the Area under the Normal Curve (AUC) into Cohen’s d, Pearson’s r pb,
Odds-Ratio, and Natural Log Odds-Ratio: Two Conversion Tables. Eur. J. Psychol. Appl. Leg. Context 2018,
10, 35–47. [CrossRef]
84. Roley, S.S.; Blanche, E.I.; Schaaf, R.C. Understanding the Nature of Sensory Integration with Diverse Populations;
PRO-ED: Indianapolis, IN, USA, 2007; ISBN 978-1-4164-0332-6.
85. Schoen, S.; Miller, L.J.; Sullivan, J.C. Measurement in Sensory Modulation: The Sensory Processing Scale
Assessment. Am. J. Occup. Ther. 2014, 68, 522–530. [CrossRef]
86. Ministerio de Sanidad, Servicios Sociales e Igualdad. Salud Mental y Calidad de Vida en la Población Infantil;
Serie Informes Monográficos no2; Ministerio de Sanidad, Servicios Sociales e Igualdad: Madrid, Spain, 2014.
87. Van Gameren-Oosterom, H.B.; Van Dommelen, P.; Schönbeck, Y.; Oudesluys-Murphy, A.M.; Van Wouwe, J.P.;
Buitendijk, S.E. Prevalence of Overweight in Dutch Children with Down Syndrome. Pediatrics 2012, 130,
e1520–e1526. [CrossRef] [PubMed]

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